Master's of Social work student and excellent editor. I suffer from adrenal insufficiency following thirty years of prednisone and want to research how many asthmatics in my generation are undiagnosed or misdiagnosed. I'm also a professional editor.

Today is the last day of the month, which for yours truly means a frantic last ditch attempt to see our psychiatric patients who are missing in action. Either because they are very ill and have lost contact, very well and have blown us off, living in a different place now while not seeking treatment or simply uninterested. I try to see these people throughout the month, it's one of my main duties. So Last Day MIA's are the hardest to find, and I often spend the day in a very sad state of working hard while getting nothing accomplished. (MIA is NOT what we actually say, we have a convoluted and politically correct phrase in real life.) True, each try counts as an attempt to make contact and makes our Community Mental Health (CMH) happier if they read the records, but ideally I actually treat the people so we actually get paid. With CMH, these attempts are required weekly but not paid - only direct time is billable. One of my coworkers compared us to Dog the Bounty Hunter with substantial accuracy.

Naturally, I can't tell anyone (other than the patient) who answers the door where I'm from, since that would break confidentiality by revealing where the person was getting treatment from, or in this case not seeking treatment from. Now, these are poor people who usually live in neighborhoods where my white middle classness is out of place. People are suspicious of me, expecting that I am serving legal papers or selling something or asking for political contributions. So roommates and family members are not amused or willing to tell their mentally ill associate that I am there without a darn good reason which I cannot give. Even if I know the patient has signed releases to various people, I can't tell who they are when they answer the door unless they tell me their name, which virtually never happens. In any case, MIA patients tend not to have releases to anyone because of social isolation and/or an unwillingness to designate their roommate at the crack house as a participant in their treatment.

Worst of all are the people who you KNOW aren't there anymore, but you have to continue going to their (former) house weekly until CMH decides not to reauthorize them anymore, which can take up to a year. This is a total waste of time that we are not even paid for and which takes time away from people who are actually living where they say they do and needing treatment.

Bounty hunters don't have to do that. Maybe I should change careers. I bet bounty hunting pays more than social work, too!

I recently read about ultra luxury psychiatric retreats that cost over a thousand dollars a day and treat people with anxiety and depressive disorders for longer than a few days. One opinion in the post was that anyone who could be trusted with a phone cord in their room should not be inpatient, let alone staying for a week or two. People staying there were characterized as the "worried well", not people whose genuine psychiatric problems we should take seriously. The argument implied was that this is beyond the standard of care in public hospitals billing insurance, and that was a bad thing. As a mental health professional and a psychiatric patient who needs inpatient care at times, I'm not so sure.

Surely these "retreats" are private pay, profit based organizations of the most obvious kind. But at least they deliver quality care to those who can afford it. Full hour sessions with psychiatrists. Occupational therapy. Group therapy. Relaxation exercises based on Eastern practices (which I take to mean yoga and meditation). Time to form therapeutic rapport with staff treating you. Time for medications to start working. Reasonable assurance that your roommate is not a former murderer who will attempt or carry out murder on you during your stay. (Based on a True Story from my years as a social worker.) Adequate staffing at all, for that matter. Finally, time to stay while you sort out your immediate crisis and transition from crisis to a period when you can plan your life with clarity.

That's an excellent standard of care, compared to the typical level paid for by insurance at the average psychiatric unit. There, you may see your psychiatrist five minutes a day. Nurse staffing is skeletal, and there is nobody to interact meaningfully with as the need arises. Except other patients, which has some benefit but also evident drawbacks, such as other patients not being psychiatric professionals most of the time. Stays limited to two or three days if you are not psychotic, although antipsychotic medications kick in weeks faster than depression and anxiety medications. No real treatment on weekends. And that potentially deadly roommate who does not get one on one staffing.

And where did that low standard of care come from? For-profit hospitals and insurance carriers, of course. They don't pay or charge as much as the retreats, but managed care and profit seeking hospitals have sheared the quality of care away. This happens on medical units too. Just consider the isolated frail elderly person getting outpatient surgery when it is known that there will be nobody to care for them at home. Insurers do not even provide parity coverage for mental health treatment, which increases the problem. So the standard step down units of fifteen years ago that provided separate levels of care for critically ill/dangerous patients and patients transitioning from crisis to outpatient care are gone. Staffing is pared to a minimum to cut costs. Psychiatrist time is deemed too expensive for patients to do any meaningful work or understand their medications. Admission criteria ban the seriously but not dangerously mentally ill from inpatient care entirely, as if there can be no benefit to inpatient treatment beyond incarceration. Since the for profit health care trend began twenty years ago, the quality of all patient care has taken a nosedive. Due to non-parity, psychiatric patients are hit hardest of all.